ISBAR Plan of Care: Patient Assessment, Planning, and Evaluation

This assignment presents an ISBAR (Introduction, Situation, Background, Assessment, Recommendation) plan of care for a 91-year-old female patient diagnosed with caecal cancer and a small bowel obstruction, along with a complex medical history including PVD, COPD, and other conditions. The plan addresses the patient's immediate needs, focusing on pain management, constipation, and respiratory issues. It outlines specific nursing interventions, including dietary considerations, hygiene maintenance, and exercises to promote patient well-being. The plan emphasizes the importance of palliative care and the patient's religious preferences. The report also includes expected outcomes, outcome criteria, and a section for evaluation, highlighting the challenges of managing the patient's conditions. The plan emphasizes the need for compassion and personalized care to improve the patient's quality of life.

1
ISBAR – Plan of Care
Identification
Please remember to use three identifiers to confirm correct patient
ISBAR Plan of Care
Patient name:
UR:
Age/Date of Birth: Gender:
Agnes Jenkins 91 years Female
Situation: Admission Diagnosis
Caecal Cancer and Small bowel obstruction has
been diagnosed
Background: History
Suffering from PVD, COPD, GORD, Hypertension,
Right carpel tunnel repair, Glaucoma, CVA, chronic
back pain, constipation, diverticular disease,
reduced thyroid function, legally blind
Assessment
Objective Data Subjective Data
 Neurological Assessment- 8/ 24  Feels a lot of pain
 Sedation Score- 8/ 24  Nauseous
 Pulse rate- Normal  Needs assistance 24*7

ISBAR – Plan of Care
2
Problems (actual or potential):
The actual problems being faced are Bowel obstruction and Caecal cancer along with erratic breathing, Hypertension, CO
Priority of problems:
The first diseases of the patient that would be addressed is soothing the back pain, addressing constipation and other rela

ISBAR – Plan of Care
3
Planning: Recommendations
Expected Outcome Outcome
Criteria
Palliative Care will help in giving relief to the patient
avoiding any painful treatments.
It will help in providing relief to the patient. Minimization of
pain can be tested
Maintenance of proper hygiene and cleanliness. This will help in improving the surroundings and reduce
chances of further infections. Reduction in further infections
to the wounds can be observed.
Dietary control and management is one of the key care
plan component.
Better nutrition will lead to better palliative care providing
comfort. Improved energy levels can be tested.
Since mobility is zero, the basic exercises that can be
done while sitting or resting.
This will help in energizing the patients and can be measured
by the improved breathing.
Since patient is nauseous, appropriate medicines for
nausea can be given.
The resolution of the nausea problem can be addressed.
Nursing Interventions
Intervention
s
Rational
e
Dietary interventions in the care plan The patient is old and needs adequate energy and nutrition.
Hygiene Maintenance Cleanliness in the surroundings is critical for the better health of the patient
Exercises Light exercises will help in inducing activeness in the body due to
reposition.
Bismuth subsalicylate Will reduce the nausea and also help in meeting the gas related problems
that patient in incurring

ISBAR – Plan of Care
4
Palliative care treatment Palliative care is necessary because of the declining life expectancy makes
it necessary to avoid any care plans or treatments and cause further pain to
the patient.
Religious beliefs The patient wants the visit of pastor and meeting this will give her inner
peace and satisfaction thus making her peaceful.

Evaluation:
the cancer and other diseases that have been found in the patient will be a torturous and difficult venture for the patient. Therefor
5
ISBAR – Plan of Care
Signature Date